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Virginia Regulatory Town Hall
Department of Behavioral Health and Developmental Services
State Board of Behavioral Health and Developmental Services
Rules and Regulations For Licensing Providers by the Department of Behavioral Health and Developmental Services [12 VAC 35 ‑ 105]
Action Compliance with Virginia’s Settlement Agreement with US DOJ
Stage Final
Comment Period Ends 7/22/2020
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7/22/20  10:17 pm
Commenter: Pam Miller

CAP-Regulatory Action

Under 12 VAC35-105-170 C, providers are required to submit a corrective action plan (CAP) outlining actions to be taken to minimize the possibility that the violation will occur again.  This requires correcting any systemic issues which might lead to the issue in another location operated by the provider. Providers desire to provide the best supports possible to our individuals. Minimizing the possibility of violation is a reasonable goal. 

Under 12 VAC35-105-170 H, providers are held to an unachievable standard by stating the corrective action plan would prevent recurrence.  The provider is expected to include the expectation that recurrence will not happen as part of the Quality Improvement Plan.  

The standard of preventing recurrence is an impossible standard to meet. For providers with multiple locations, this is particularly difficult.  During a review at one site, an issue such as a small maintenance need could be cited and then later a non-related issue that falls under the regulation at another location is cited.  If these are cited on different CAPs under the same regulation, multiple citations would be considered a "systemic" issue. 

To have a Corrective Action Plan that covers all contingencies and ensures no future violations is impossible and will lead to additional citations.  The purpose of a CAP should be to improve services and ensure that supports are best practice.   To expect perfection across numerous programs and situations when working with human beings is not realistic.  

12VAC35-105-170-H and 12VAC34-105-D-3 should be removed from the Final regulations.

CommentID: 84184